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Outline for a talk given by Roger Litten at the College of Psychoanalysts-UK International Conference PSYCHOANALYSIS AND STATE REGULATION, 31 March-1 April 2006 |
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We are faced with a move towards the state regulation Of what are called talking therapies in this country The question is how to oppose it The most obvious difficulty Is the apparent self-evidence of the need for regulation The need for qualifications and standards to counter The risk to the public posed by unqualified or incompetent practitioners This makes it difficult to even raise the question Why we need regulation of these forms of therapy Especially when the call for regulation is supported by The majority of professional bodies themselves The debate in this country already seems to have moved beyond Question of why, of whether regulation is necessary To the pragmatic details of how to be regulated Losing sight of any basis for attempts to oppose principle of regulation itself In order to find ways to effectively oppose regulation Thus need in the first instance to find ways to bring The apparent self-evidence of the need for regulation back into question I would like to suggest that the most effective way of doing this is to Examine the relation between the why and the how of regulation Introduce questions like well why now, why like this Make visible logic at stake in move towards regulation That will allow us to identify possible basis for effective opposition I would like to start with a distinction between what we might call the rationale and the logic of regulation I propose to examine the common rationale of the call for regulation In an attempt to demonstrate that there is an alternative logic at stake I want to focus on the articulation between the current discourse of regulation and a more complex and insidious discourse of evaluation, accountability, audit I will suggest that it is this discourse of evaluation and audit That lies behind the government's push towards state regulation of the talking therapies And that must be exposed as the hidden stake of the discourse of regulation We start at the level of the accepted rationale for regulation Which can be summed up in the common refrain of The need for public protection And the maintenance of standards of practice I would suggest that already here in the two elements of this refrain That has become so familiar that we barely question the self-evidence Of the association between public protection and the maintenance of standards. We have the nuclear articulation between regulation and evaluation I would like to follow through this rationale for regulation To the point where this discourse articulates with the question of evaluation In order to expose the alternative logic at stake and the contradictions entailed By following this approach I hope we can arrive at the point where it becomes possible To demonstrate that not only does regulation not achieve what it claims to set out to achieve Ie does not do what it says on the tin But also entails consequences and effects That just happen to be the very opposite of what it claims In other words we set out from a rationale for regulation Elaborated on the basis of a discourse of public protection Only to stumble into a system of audit and accountability That at certain points can be seen to provide no protection at all To the very people it claims to serve In this way hope to be able to elaborate a symptomatic and diagnostic reading of the discourse of regulation That will provide the basis for effective opposition to that discourse By elaborating a psychoanalytic critique of the logic at stake I have suggested that it is the apparent self-evidence of the rationale for regulation That makes it so difficult to challenge, To even raise the question of why we need regulation This difficulty getting a hearing for the question why Should not in the first instance prevent us introducing questions Such as well why now and why like this? The prospect of regulation of the psychotherapies has been on horizon for decades Yet it is only now that the government seems to have built up a head of steam to push it through We will thus start with the question why now in order to return to the question why at all There are at least two possible answers to the question why now One is extremely localised and the other more complex and diffuse If you will allow me I hope to be able to trace out a relation between them In order to provide the framework for a critical examination of the apparatus of regulation Outlined in current proposals for the regulation of the talking therapies by the HPC In the first instance I think it would be a mistake to lose sight of the fact that This programme of regulation is not aimed at psychoanalysis in particular Nor even necessarily at the talking therapies in general But is rather part of a broader programme of governmental regulation Being unrolled on various fronts in security, education and health And which is only now being extended into the sphere of the 'talking therapies' Which will by implication include psychoanalysis at one level or another Suggest that this makes it all the more difficult for us to oppose But at the same time even more imperative for us to do so Because if psychoanalysis is not able to mount a critique of these proposals Then who can we expect to do so on our behalf? Have suggested that there are two possible answers to question why now I will start with the most localised answer, which can go under the name of Dr. Harold Shipman The doctor who murdered all his patients for no apparent reason Apart from the fact that he seemed to enjoy doing it, was addicted to killing We can use this singular instance of the flagrant betrayal of everything the figure of the doctor is supposed to stand for to mark a point of breakdown in the traditional relation between patient and doctor The loss of trust in the figure of medical authority Accompanied by a loss of confidence in the profession as a whole The impact of the Shipman case Must of course be situated in relation to other contemporary medical scandals Alder Hey, the Bristol enquiry, Cases of medical negligence and incompetence That appear to have continued undetected for years These have raised justified questions about the ability of the GMC, The body representing medical authority and professional self regulation, To safeguard the public from malpractice by its own members The failure of the professional body to ensure public protection And maintenance of standards of practice within the medical profession Then leaves the door open to a demand for State intervention These scandals thus mark a point of erosion of the autonomy of professional bodies The rise of calls for external monitoring and independent enquiries For the removal of the regulatory role of a professional body seen to have failed in its responsibilities to the public to be replaced by a system of regulation by independent bodies that would be independent, transparent, and accountable to the State I am using this example of the position of one of the more influential professional bodies in the UK as the quickest way to sketch the shift away from a culture of professional self-regulation in this country Towards a culture of accountability and State regulation I am aware that this is a very rapid sketch, taking a number of shortcuts, In what is in itself a highly complex problematic I am attempting only to situate the most general framework of this shift In order to go on to identify pressure points in the argument for regulation Hoping to demonstrate that we can use a common logic of analysis at each point The perceived failure of the system of self-regulation by professional organisations Their failure to safeguard their position of responsibility and medical authority Coincides with a breakdown in relation of trust between patient and doctor And ultimately with a loss of confidence in the profession as a whole This opens the door of the clinic to the intervention of an independent third party Assumes an external point of arbitration in the name of transparency and accountability Able to hear complaints from patients and to respond to them And ultimately to judge on adequacy of professional practice This shift in the external legal and statutory framework of professional practice Then entails profound modifications, some of which have already been outlined in Christopher Bollas' work on confidentiality, for the internal dynamics of a psychoanalytic clinic founded on the privileging of the transferential relation between patient and analyst Here I only want to sketch in Framework of this shift from responsibility to accountability As basis of rationale for introducing an independent State regulator As the background to the introduction of the Health Professionals Council Regulatory body for health professions supplementary to medicine In first instance the HPC appears no more than glorified complaints body With a remit to hear complaints laid by members of the public against practitioners And to provide independent judgement of legitimacy of those complaints Together with statutory powers to enforce sanctions in appropriate cases It is of course possible to trace in detail The subtle and progressive extension of this remit on a number of fronts From hearing complaints, to judging fitness to practice, To the issuing or with-holding of licence to practice To the vetting of qualifications and accreditation of training courses, To having a say not just in the curricula of those training courses But also in the criteria according to which trainees are selected All of this in the name of protecting the public By maintaining standards of practice and training Here I wish to highlight just one aspect of HPC's work Its responsibility for drawing up standard Codes of Ethics and Practice That will be binding for each profession under its remit Clear that for an external body to hear complaints against practitioners from a wide range of professions It will need objective standards against which competence can be judged This is one way of understanding the increased importance Being given to Codes of Professional Practice Objective standards of practice to which members of a profession adhere These standards of practice made available to clients And form the basis for deciding whether there are valid grounds for complaint As well as the basis for judgement by HPC whether that complaint is legitimate Whether there has been a failure to meet standards of practice as laid out in that code The judgement of the adequacy of practice, or the legitimacy of a complaint Thus comes to be reduced to the question of whether The stated codes of practice have been breached or not We thus find codes of ethics and practice effectively reduced to a customer charter A psychoanalyst or psychotherapist provides a service No different from a plumber or a mechanic That requires protection of customer rights with a service guarantee Complaints procedures and refunds if not fully satisfied and recourse to an independent regulatory body if something goes wrong This is perhaps a slightly facetious way of approaching what is undoubtedly a complex and serious question But once again we find ourselves drawn into a culture in which The need for Codes of Practice becomes so widely accepted and so self evident that it becomes difficult to critically examine what is involved Without diminishing the importance of this question We would need to examine role played by contemporary codes of practice Within the framework of the shift from a discourse of responsibility to one of accountability From a conception of ethics and responsibility internal to the relation between patient and practitioner To a notion of accountability as a form of recourse to an independent court of appeal the introduction of a site for independent third party judgement of the adequacy of practice made possible on basis of the standards of practice defined by those very codes This would be one way of examining changes in the vocabulary, content and role of these codes The proliferation of codes of practice and ethics within the profession of psychotherapy Increasingly comprehensive attempt to provide for every possible ethical dilemma or scenario Provide guideline how to proceed when faced with various ethical dilemmas Fill the gaps of every possible source of risk with a guarantee Could suggest that at root all these codes are designed to safeguard relation between patient and practitioner In first instance safeguard rights of patients, protect patients from practitioners But also ultimately for protection of practitioners too Everyone knows where they stand Want to question what is at stake in this rationale Suggest that this very proliferation of codes designed to safeguard that relation Could be read as a sign of difficulties posed by the nature of that relation itself Suggest that this understanding of the ethics of relationship between analyst and analysand This reduction of relation of transference to commercial contract between service provider and consumer entails a commodification and objectification of what is at stake in that relationship These attempts to give positive form to the ethics of that relationship Would require far more detailed examination than is possible here because this is precisely one of the major points at which responsibility is seen to articulate with accountability But also point at which this shift of framework Has the effect of skewing the basis of the very relation it seeks to safeguard Point at which attempts to safeguard that relation in this manner Slide towards a complete perversion of that relation That in the end provides no protection or safeguard at all Again this is a slightly hasty approach to what is fundamental question Would need to be approached in detail via psychoanalytic theory of transference Examining rise of notion of the Therapeutic Alliance in contemporary psychotherapy Understanding of nature of that relation as the basis for psychotherapeutic treatment Clear that this foregrounding of notion of therapeutic alliance Underlies the notion of the therapeutic relation as a contract between equal partners Contract agreed at the start of treatment to lead towards agreed ends Point at which customer charter notion of the therapeutic contract Involves complete misunderstanding of what is at stake in transferential relation And hence basis for any possible therapeutic efficacy of psychoanalytic work in general But also point at which entails profound and subtle slide towards Abdication of responsibility for the psychoanalytic position In favour of an external guarantee of false accountability Suggest that subscription to culture of accountability As filtered through discourse of codes of practice In fact involves increasing abdication of professional responsibility Not only lose sight of subjective ethics of analytic relation The true source of analytic responsibility And in end the only guarantee of psychoanalytic efficacy But also amounts to a profound betrayal of source of effectiveness of psychoanalytic work Culture of accountability left protecting empty shell of psychoanalytic relation With an external apparatus of contract and guarantee Point at which we would have to question whether it is not the psychoanalytic organisations themselves That have lost sight of this question Explain not only vulnerability to demands of regulation Silence in face of these developments But also their eagerness to comply with the State's wishes To mask their own difficulties at this point |
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| August 11 2006 |
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